To test the effect of a training program on four measures of clinical practice: 1) routine HIV testing; 2) performance of physical examination; 3) risk-reduction counseling; and 4) patient education

Study Design

A controlled intervention trial comparing the effect of a provider training course on clinical practices in a district receiving and a district not receiving the training

Location

Five public health facilities in Lobatse Town Council District (intervention) and a hospital and six public health facilities in Southeast District in Botswana (comparison). The districts were selected on four criteria: 1) average or higher proportion of genital ulcer disease (GUD) among patients making sexually transmitted infection (STI) visits; 2) low number of clinics; 3) clinics located relatively close together; and 4) proximity of districts. The clinics were selected for having an average of 10 or more STI patient visits per month and having the ability to obtain informed consent from patients. A mental facility and a prison clinic were excluded for inability to obtain consent.

Participants

Results were the reports of 185 patients in Lobatse and 124 patients in Southeast District during exit interviews after a clinical visit for an STI. Eligibility criteria included female patient 16-49 years old presenting with genital ulcer disease (GUD) and/or vaginal discharge or lower abdominal pain (VD/LAP); and male patient 16-49 years old presenting with GUD and/or urethral discharge. Providers referred all patients who met inclusion criteria to an interviewer who obtained informed consent.

Intervention

All nurses, nurse midwives, and medical officers in the Lobatse Town Council were entitled to training, and 194 of 212 providers were trained during eleven 3-day sessions from September 6 to October 28, 2004. The curriculum was designed for clinical training in resource-limited settings, including interactive case studies and films on patient-centered care, sensitive female pelvic examination, risk-reduction counseling, and HIV post-test counseling. Sessions were facilitated by master trainers from the National STI Training and Research Center and core trainers. Patients who consented to participate in exit interviews were interviewed 2 months after the providers received their training. Patients who just completed a visit that included STI care were referred for the interview. A trained interviewer read standardized questions to the patient about their clinical visit. The patients also were asked to rate certain aspects of their health care on a scale of 1 to 5.

Primary Outcomes

The primary outcome was pre- and post-intervention effects within each intervention group; specifically, changes in dichotomous variables, such as condom use and alcohol and crack cocaine use assessed using the McNemar test. Descriptive statistics were compiled on participants' demographic characteristics, sexual behavior, substance use, and experiences of violence.

Results

For all four measures of clinical practice, patients at training clinics were significantly more likely to report the desired outcome than patients at the comparison clinics. Thirty-three percent of patients at training clinics had an HIV test compared to 14% at comparison clinics (p<0.001). Ninety-one percent of patients at training clinics reported having enough opportunity to talk privately with the provider about HIV testing compared with 33% at comparison clinics (p<0.001), and 87% of the patients at training clinics were offered an HIV test compared with 29% at comparison clinics (p<0.001). Among patients offered an HIV test, 38% of 161 patients at training sites and 50% of 36 at comparison sites agreed to be tested. Patients at training clinics were significantly more likely to report having a physical examination than at comparison clinics (98% vs. 64%, respectively, p<0.001). Patients at training clinics rated the quality of care more highly than did patients at comparison clinics, specifically when answering the following questions: 1) did you feel the health worker gave you treatment for your problem?; 2) did the health worker give you information about the nature of your problem?; 3) did the health worker help you make a plan so that you could better prevent this problem in the future?; and 4) on the whole, were you satisfied with the care you received for your problem today? Patients at training clinics were significantly more likely to report what they had learned about their HIV risk from the provider than were patients at comparison clinics (65% vs. 32%, respectively; p<0.001).

More patients at training clinics were treated by nurse midwives (31%) than at comparison clinics (16%) (p=0.003) and correspondingly fewer by nurses. Significantly more patients had visits for follow-up care at training clinics than at comparison clinics (29% vs. 10%, respectively; p<0.001) and correspondingly fewer were first visits.

Conclusion

The authors concluded that an STI training program for clinicians was associated with patient reports of higher rates of HIV testing, physical examination, and risk reduction counseling and better HIV risk education in the setting of an STI visit. The authors also suggested that patient reports can be used to evaluate whether tasks were performed by providers.

In Context

This study is among the first reports of routine HIV testing for STI patients in a resource-limited setting since June 2004, when the WHO and UNAIDS recommended it for STI clinics or other clinics that provide STI care. In this study, the difference in the percentage of patients who had an HIV test in training (33%) and comparison clinics (14%) was within the range reported in a study done in England.(1) The present study adds to the limited data demonstrating an effect of STI training in resource-limited settings on conducting a physical examination(2, 3) and counseling STI patients on their HIV risk.(4, 5)

Quality Rating

As a community intervention trial with cluster assignment of intervention and comparison, this study is weakened by nonrandomized assignment of treatment. Differences in outcome measures could have been confounded by unmeasured differences in the providers and patients in the districts, as the authors acknowledge. The design was limited to measuring the outcomes at one time period (2 months after training), so there are no data to show whether training effects persisted over time. In addition, no pre-intervention measure was made to estimate the change related to the training program. The intervention and control districts were adjacent, and may have resulted in contamination of the study and control populations may have occurred if they talked about their clinical experiences. In addition, it is not revealed whether patients learned of their HIV test result. Finally, the number of responses from patients who "strongly agree" that quality of care was high may have resulted from acquiescent response bias. In short, this is a lower-quality intervention trial.

Conclusion

The authors conclude that this multifaceted training program was associated with higher rates of HIV testing, physical examination, and risk-reduction counseling and with better HIV risk-reduction counseling.

Implications for Resource-Limited Settings

This study provides some data that training on integrating HIV testing into STI care had a positive impact on patients' uptake of HIV testing and resulted in increased performance of physical examinations, risk-reduction counseling, and patient education. Due to the weaknesses of the study design, however, confidence in the results must be limited. Further studies are needed to show whether such training has a long-lasting impact on patient care and education.